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Summary of the impact

DAFNE (Dose Adjustment for Normal Eating) is a structured training
programme in Type I diabetes self-management whose development was led by
researchers at the University of Sheffield. As a direct result of these
research findings, and the demonstration of improved outcomes, there has
been a change in the approach to management of Type I diabetes from
hospital based, doctor/nurse centric care to patient centred
self-management. The Department of Health now mandates structured training
in England and Wales, with DAFNE courses provided in a third of UK
centres.

Underpinning research

Biomedical outcomes among adults with Type 1 diabetes were poor in the UK
compared to other countries in part due to inadequate self-management
among those with the condition. A research project was launched in 1998,
led by Heller (University of Sheffield, 1998-date), to develop effective
models of training in the skills of insulin therapy. A German model, whose
biomedical benefit had been demonstrated in a small, non-randomised trial,
was identified and a clinical team from Sheffield, together with
colleagues from North Tyneside and King's College, London, visited the
German centre and determined that the intervention might be effective in a
British setting. Heller was awarded a grant (£300k) by the British
Diabetic Association to adapt the German model for delivery in a UK
setting and to fund a randomised clinical trial in Sheffield and two other
centres that would measure biomedical, quality of life and other
psychosocial outcomes (parameters that had not been previously evaluated).
The intervention, formatted for a British diet, was delivered over 5 days
but in an outpatient setting (as opposed to inpatients in Germany). Adults
with established Type 1 Diabetes were recruited from the three centres and
were randomised to undertake the course immediately or else act as
`standard therapy controls' for 6 months, before undertaking the course
themselves.

Blood glucose control improved significantly and substantially (to a
level of improvement that would reduce the chances of developing diabetic
eye and kidney disease by over 25%) in those undergoing skills training,
while it was unchanged in the standard therapy controls. However, blood
glucose in these controls improved 6 months later after they had, in turn,
undertaken their skills training. The intervention group continued to show
improved blood glucose control 12 months following their course.
Psychosocial outcomes (including quality of life) improved markedly and
were maintained for the full 12 months [R1]. A health economic
evaluation was undertaken by health economists at the University of York
(with clinical input from Heller and Sue Roberts, National Clinical
Director for Diabetes, from North Tyneside General Hospital) and published
in 2004 [R2], which reported the intervention to be strongly cost
effective and that it would pay for itself in 4-5 years due to the reduced
complication rate expected from improved glycaemic control. An evaluation
of the original trial cohort was undertaken after another 3 years and
demonstrated that, while all blood glucose control had slipped, it
remained significantly improved and psychosocial outcomes were still
strongly positive [R3].

Details of the impact

The research provided strong clinical evidence that skills training in
the management of insulin therapy was effective in an outpatient setting
and led to the creation of a 5-day outpatient based course with
accompanying materials for use on UK patients. This has led to a paradigm
shift in the approach to the management of Type 1 Diabetes from hospital
based, doctor/nurse centric care to user centred self-management that has
delivered the following impacts:

Change to clinical guidelines

Publication of the paper in the BMJ plus the subsequent responses from
the UK diabetes community prompted NICE to include within the scope of
guidelines on management of Type 1 diabetes a review of the literature on
diabetes related education. The guidelines state in paragraph 7.3 "NHS
trusts, primary care organisations and general practices should ensure
that responsibility is clearly defined for offering and providing
educational programmes for people with diabetes and for considering
referral to the DAFNE programme as one option for people with type 1
diabetes" [S1].

Paragraph 1.4 of the same NICE guidance, states "It is considered that
the Dose Adjustment for Normal Eating (DAFNE) programme may be a
suitable option for individuals with type 1 diabetes, being one means of
enabling people to self-manage this condition." [S1].

In addition, in `Understanding NICE guidance — information for people
with diabetes, and the public' it states on pages 6 and 7: "What has
NICE recommended? NICE has recommended that all people with diabetes
should be offered structured education, provided by a trained specialist
team of health professionals. NICE considers the team should include a
diabetes specialist nurse" [S2].

It also goes on to say "The DAFNE (short for Dose Adjustment For
Normal Eating) training course is one example of a patient-education
model for people with type 1 diabetes. A DAFNE course lasts 5 days and
teaches groups of people to tailor their insulin doses according to the
amount of starchy foods they eat and their lifestyle. DAFNE is a
`structured' programme." [S2].

DAFNE is also the only structured skills training course for adults with
Type 1 diabetes that meets the requirements of a Department of Health
report from the Patient Education Working Group [S3]. To quote
Rosie Winterton MP (Minister of State for Health Services in 2005), "The
DAFNE and DESMOND (Diabetes Education and Self-Management for Ongoing
and Newly Diagnosed) education programmes provide a nationally-led,
evidence-based approach for type 1 and type 2 diabetes" [S3,
page 3].

Current clinical status

The Department of Health initially funded a roll-out across the country
to 10 additional centres within the Expert Patient Programme and DAFNE is
now delivered by 75 specialist diabetes services in the UK, Northern
Ireland and the Republic of Ireland [S4]. Based on the number of
acute Trusts delivering diabetes services (patients with Type 1 Diabetes
are cared for in secondary care), this represents around 35% of secondary
centres [S5].

Since 2008, more than 25,000 adults with Type 1 diabetes have completed a
DAFNE course in the UK [S6] representing approximately 15% of
adults with the disease in England and Wales (figures estimated from those
contained in [S7]). Currently, there are 550 courses offered every
year, with around 4000 new DAFNE graduates.

DAFNE has also been exported to Australia (as Oz DAFNE), being delivered
in 14 centres including New Zealand. Teams from Spain, South Africa,
Nigeria and Kuwait have recently travelled to the UK to observe DAFNE and
receive training. The numbers of graduates in other countries with growing
DAFNE programmes since 2008 are as follows: Australia, New Zealand and
Singapore (2697), Kuwait (159) [S8].

Economic impact

DAFNE has delivered cost savings to the NHS estimated by NICE to be £48
million per year nationally [S9].

Sources to corroborate the impact

S1. NICE Technology Appraisal Guidance 60: Guidance on the use of
patient-education models for diabetes. Issue date: April 2003: